Saturday, June 11, 2016

FEAR AND ANXIETY

“Anxiety” is a modern term that does not have an exact equivalent in Chinese medicine.
There is no Chinese medicine term that corresponds exactly to what we call “anxiety” but several ancient Chinese disease entities closely resemble anxiety.  The four main disease entities that correspond  to Anxiety are:

“Fear and Palpitations” (Jing Ji)    
 “Panic Throbbing” (Zheng Chong)       
 “Mental restlessness” (Fan Zao)      
 “Agitation” (Zang Zao)    

Fear is the emotion that pertains to the Kidneys and I would like to make three points.  Firstly, “anxiety” does not correspond only to “fear”: it also corresponds to “worry” and “pensiveness” in Chinese medicine.

Secondly, we normally say that fear depletes Kidney-Qi and it makes Qi descend.  The Su Wen in chapter 39 says: “Fear leads to loss of Jing which results in obstruction of the Upper Burner, when this is obstructed Qi cannot return [to it] and this causes distension of the Lower Burner, that is why it is said that Qi sinks.”

This statement from the Su Wen is interesting in that it says that fear blocks the Upper Burner (resulting in Qi of the Lower Burner to descend): this would imply that fear does not simply “make Qi descend” (as we usually say) but that it also causes some Qi stagnation in the Upper Burner.

I personally think that fear actually makes Qi rise and fright makes Qi descend.  The description of Jing Ji by Zhang Jing Yue implies that, in fear, Qi rises: “In Fear and Palpitations [Jing Ji], the Heart, Spleen, Liver and Kidneys are involved.  Yang is connected to Yin and the Heart to the Kidneys. [In this disease] the upper part of the body is restless because it cannot link with the lower part; Heart-Qi is deficient and cannot connect with the Jing [of the Kidneys].”

Dr Zhang’s description of the pathology of Zheng Chong also implies that fear makes Qi rise: “In Panic Throbbing [Zheng Chong] the heart is shaking in the chest, the patient feels fear and anxiety.  There is Yin deficiency and exhaustion; there is Yin deficiency below so that the Zong Qi has no root and Qi cannot return to its origin.  For this reason, there is shaking [or throbbing] of the chest above and also throbbing on the sides of the umbilicus.

The above statements by Zhang Jing Yue are interesting because they confirm my experience according to which fear makes Qi rise (rather than descend).  In fact, in the statement above, Zhang Jing Yue says that in “Fear and Palpitations”, there is restlessness above and a disconnection between the Heart and Kidneys with Qi rising.

Thirdly, although fear is the emotion pertaining to the Kidneys, other organs also give rise to fear and anxiety and I am presenting below passages from the Su Wen and Ling Shu highlighting connections between fear and organs other than the Kidneys.

Su Wen chapter 39
Fear leads to loss of Jing which then results in obstruction of the Upper Burner, consequently leading to return [back up] of Qi and distension in the Lower Burner.”

This passage is actually similar to the passages by Zhang Jing Yue quoted above.  It makes the point that fear leads to obstruction of the Upper Burner.  It confirms the relationship between fear and Kidneys as it says that it leads to loss of Jing.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 221.

Su Wen chapter 62
Surplus of Blood leads to rage while insufficiency of Blood results in fear.”

This passage correlates fear with the Liver saying that Liver-Blood deficiency results in fear.  This is an important correlation as it is a common one in practice, especially in women (in whom Liver-Blood deficiency is common).

The “fear” deriving from Liver-Blood deficiency is related to timidity, lack of initiative, fear of acting, inferiority complex.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 334.


Su Wen chapter 19
Excessive fear lead to subjugation [of the Kidneys] by Spleen-Qi.”

This is an interesting and unusual view according to which fear leading to a deficiency of the Kidneys may be caused by a pathology of the Spleen (Earth overcoming Water).  This would occur when the Spleen is affected by pensiveness and worry.  This type of fear therefore is close to worry.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 118.

Su Wen chapter 23
The disorder of Heart-Qi causes belching; the disorder of Lung-Qi causes cough; the disorder of Liver-Qi causes excessive talking; the disorder of Spleen-Qi causes acid reflux; the disorder of Kidney-Qi causes yawning and sneezing; the disorder of Stomach-Qi causes rebellious Qi, hiccup and fear.”

Note by Wang Bing: “When the Stomach is hot, the Qi of the Kidneys is feeble and weak; hence this causes fear. When the Earth harms the Kidneys, the Shen has fear.”

This is an interesting passage that relates fear to rebellious Stomach-Qi. I think this would be particularly Panic Disorder (panic attacks).  The Great Luo of the Stomach (called Xu Li) goes to the heart and it affects it on a physical and mental-emotional level.  On a physical level, it may cause palpitations or tachycardia.  On a mental-emotional level, it may cause a panic sensation with a feeling of energy rising to the chest and head.  ST-40 Fenglong would be the point to use for this.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 150.

Ling Shu chapter 8
The Liver stores Blood and the Blood houses the Hun. Deficiency of Liver-Qi causes fear while excess of Liver-Qi causes anger. Constant fear and pensiveness will damage the Shen and damage of the Shen in turn will lead to fear and seminal emissions.  Excessive fear and fright will scatter the Shen and make it difficult to be contained [to be gathered].  Excessive fear and pensiveness will damage the Shen.  Damage of the Shen in turn will lead to deprivation of the ability to control oneself due to fear.  Constant fear without relief will damage the Jing and damage of the Jing will cause weakness of bones, impotence and habitual seminal emissions.”

The first sentence of this passages relates fear to a deficiency of Liver-Qi (chapter 62 of the Su Wen related it to Liver-Blood deficiency). Liver-Qi deficiency does exist and it usually causes depression: therefore, in this case, the person would be anxious and depressed.

The further sentences of this chapter say that fear damages the Shen and the Jing (and therefore Kidneys).

1981 The Yellow Emperor’s Classic of Internal Medicine- Spiritual Axis (Ling Shu Jing), People's Health Publishing House, Beijing, first published ca 100 BC, p. 23.

END NOTES
1.  Unschuld P Huang Di Nei Jing Su Wen, University of California Press, Berkeley, 2011, p. 401-2.

Friday, May 13, 2016

MEMORY IN CHINESE MEDICINE

THE SHEN () OF THE HEART

The Shen of the Heart plays a prominent role in memory partly by itself and partly because it coordinates the Yi of the Spleen and the Zhi of the Kidneys which also play a role in memory.

The Shen of the Heart plays a role in memory in the sense of memorizing but especially also in intrinsic memory (see below).

Information that we have to consciously work to remember is known as explicit memory, while information that we remember unconsciously is known as implicit memory.  Implicit memory is  not always unconscious as it includes what we call “muscle memory” which in psychology is called “procedural memory” (see below).

Explicit Memory
When we are trying to intentionally remember something (like the names of acupuncture points or a list of dates for a history class), this information is stored in our explicit memory. We use these memories every day, from remembering information for a test to recalling the date and time of a doctor's appointment. This type of memory is also known as declarative memory, since we can consciously recall and explain the information.

Some tasks that require the use of explicit memory include remembering what we learned in a class, recalling a phone number, writing a research paper, and remembering what time we are meeting a friend, etc.

There are two major types of explicit memory:

1.     Episodic memory: These are our long-term memories of specific events, such as what we did the day before or our high school graduation.
2.     Semantic memory: These are memories of facts, concepts, names, and other general knowledge information.


Implicit Memory
Things that we do not purposely try to remember are stored in implicit memory. This kind of memory is both unconscious and unintentional. Implicit memory is also sometimes referred to as non-declarative memory, since we are not able to consciously bring it into awareness.

Procedural memories, such as how to perform a specific task like swinging a baseball bat or sewing, are one type of implicit memory since we do not have to consciously recall how to perform these tasks. While implicit memories are not consciously recalled, they still have an influence on how we behave as well as our knowledge of different tasks.

Some examples of implicit memory include singing a familiar song, typing on our computer keyboard, daily habits, driving a car, riding a bicycle, sewing.

Riding a bicycle is another great example. Even after going years without riding one, most people are able to hop on a bike and ride it effortlessly.

The Shen of the Heart plays a role in both extrinsic and intrinsic memory but it is especially the one that is responsible for intrinsic memory, which the Yi of the Spleen and the Zhi of the Kidneys are not.







Heart-Blood deficiency and Heart-Yin deficiency are a common cause of poor memory.

HEART-BLOOD DEFICIENCY 
Palpitations, dizziness, insomnia, dream-disturbed sleep, poor memory, anxiety, propensity to be startled, dull-pale complexion, pale lips.
Tongue: Pale, Thin, slightly dry.
Pulse: Choppy or Fine.
Key symptoms: palpitations, insomnia, poor memory, Pale tongue.
Acupuncture
Points: HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, Ren-4 Guanyuan, BL-17 Geshu (with moxa), BL-20 Pishu.
Method: all with reinforcing method. Moxa can be used.

Herbal formula
Shen Qi Si Wu Tang Ginseng-Astragalus-Four Substances Decoction.

Three Treasures
Calm the Shen (variation of Gui Pi Tang).


HEART-YIN DEFICIENCY 
Palpitations, insomnia, dream-disturbed sleep, propensity to be startled, poor memory, anxiety, mental restlessness, dry mouth and throat, night sweating.
Tongue: no coating, deep midline crack reaching the tip.
Pulse: Floating-Empty. 
Key symptoms: palpitations, mental restlessness, night-sweating, tongue without coating.
Acupuncture
Points: HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, Ren-4 Guanyuan, HE-6 Yinxi, SP-6 Sanyinjiao.
Method: all with reinforcing method, no moxa.

Herbal formula
Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

Women’s Treasure
Heavenly Empress (variation of Tian Wang Bu Xin Dan).

THE YI () OF THE SPLEEN

The Chinese character for the mental aspect of the Spleen is Yi  which can mean “idea” or “intention”.

The Yi resides in the Spleen and is responsible for applied thinking, studying, memorizing, focusing, concentrating and generating ideas.

The Post-Natal Qi and Blood are the physiological basis for the Yi. Thus if the Spleen is strong, thinking will be clear, memory good and the capacity for concentrating, studying and generating ideas will also be good.

If the Spleen is weak, the Yi will be dull, thinking will be slow, memory poor and the capacity for studying, concentrating and focusing will all be weak.

The Spleen is responsible for memory in the sense of studying, concentrating, focusing and memorizing data in the course of one’s study or work.

Note that the Chinese character for “Yi” is based on the “heart” radical.  This indicates two things.  Firstly, it indicates that the memory of the Spleen depends also on the Heart.  Secondly, it refers to the Shen’s coordinating and integrating function in respect of the Hun, Po, Yi and Zhi.


SPLEEN-BLOOD DEFICIENCY
Poor appetite, slight abdominal distension after eating, tiredness, lassitude, dull-pale complexion, weakness of the limbs, loose stools, poor memory, thin body, scanty periods or amenorrhoea.
Tongue: Pale, Thin and slightly dry.
Pulse: Choppy or Fine.
Key symptoms: tiredness, slight abdominal distension, scanty periods, Pale tongue.
Acupuncture
Points: Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Ren-4 Guanyuan, BL-17 Geshu (with direct moxa).
Method: reinforcing method.  Moxa is applicable.

Herbal formula
Gui Pi Tang Tonifying the Spleen Decoction.

Three Treasures
Calm the Shen (variation of Gui Pi Tang).


THE ZHI () OF THE KIDNEYS

The word Zhi  has at least three meanings:
1. it indicates “memory”
2. it means “will power “
3. it is sometimes used to indicate the “five Zhi”, i.e. the five mental aspects Shen, Hun, Po, Yi and Zhi itself.

In the first sense, the Kidneys influence our capacity for memorizing and storing data. Some of the ancient doctors even said that the Yi of the Spleen and the memory of the Kidneys are almost the same thing, except that the Yi is responsible for memorizing in the course of studying and the Zhi of the Kidneys is responsible for the storing of data over the long term.

Tang Zong Hai says: “Zhi indicates Yi with a capacity for storing [data]”.

The character for Zhi is indicated below.  It is composed of Shi on the upper part and the “Heart” in the lower part.



KIDNEY-YIN DEFICIENCY
Dizziness, tinnitus, vertigo, poor memory, hardness of hearing, night-sweating, dry mouth and throat at night, lower backache, ache in bones, dark-scanty urine, infertility, premature ejaculation, tiredness, lassitude, slight anxiety.
Tongue: normal-coloured without coating.
Pulse: Floating-Empty. 
Key symptoms: backache, night sweating.
Acupuncture
Points: Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, KI-10 Yingu, KI-9 Zhubin, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai).
Method: reinforcing method, no moxa.

Herbal fomula
Zuo Gui Wan Restoring the Left [Kidney] Pill.
Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill.

Three Treasures
Nourish the Root (variation of Zuo Gui Wan).

In the sphere of thinking, remembering and memorizing there is considerable overlap between the Yi of Spleen, the Shen of Heart and the Zhi of Kidneys. The main differentiating factor is that the Spleen is  responsible for memorizing data in the course of one's work or study. 

For example, it is not uncommon for someone to have a brilliant memory in his or her field of study or research (a function of the Spleen), and yet be quite forgetful in daily life (a function of the Heart).

The Heart and Kidneys also contribute to this function, but they are also responsible for the memory of past events and implicit memory. In particular, the overlap between the Yi and the Shen in thinking activity is very close, so much so that the “Ling Shu” says in chapter 8: “The Heart function of recollecting is called Yi”.

In turn, the memorizing function of the Yi is so closely related to the Zhi of the Kidneys that the same chapter continues: “The storing [of data] of the Yi is called  Zhi”.

These passages confirm that Shen, Yi and Zhi are a continuum.

Memory and sense of Self
In modern psychology, “memory” is more that just the ability to store facts and information in our brain.  It is actually an essential part in which our consciousness exists, works and manifests itself and working memory plays an important role in our consciousness.

Even the thought “I live in the present” requires short-term memory. Even the immediate present requires involves memory – what we know about the one present moment is basically what is in our working memory.  

Working memory allows us to know that the “here and now” is “here” and is happening “now”. This insight underlies the notion, adopted by a number of cognitive scientists, that consciousness is the awareness of what is in working memory.

LeDoux says: “The self is in part made and maintained by memory and both implicit and explicit forms are involved.[1]



Thus, in a broader sense, Zhi is much more than “memory” in the sense of being able to remember past events.  The Zhi (together with the Shen) contributes to our working memory and also to the long-term memory.  Together with the Shen of the Heart, this contributes to creating our consciousness and sense of self. 



Treatment of poor memory
Memory can be stimulated by treating:

Heart (Shen): HE-7, HE-3, BL-15, BL-44 Shentang

Kidneys (Zhi): KI-3, BL-23, BL-52 Zhishi

Spleen (Yi): SP-3, BL-20, BL-49 Yishe

Du Mai (Brain/Sea of Marrow): SI-3/BL-62, Du-16, Du-20.

The Du Mai and memory
Another factor in memory is the Du Mai for three reasons. 
1)     It flows through the Heart and therefore affects Shen.
2)     It originates from the Kidneys and therefore affects Zhi.
3)     It is the vessel through which the Kidneys’ Sea of Marrow reaches the Brain.

The three main points are Du-11 Shendao, Du-20 Baihui and Du-24 Shenting.

The Lungs and memory
However, remember that there are other factors at work in memory, e.g. the Lungs affect memory by regulating the amount of Qi reaching the head.  Thus LU-7 and LU-3 are important for poor memory due to Qi not reaching the head.

The “Explanation of the Acupuncture Points” says that LU-3 can make Qi rise to treat forgetfulness, sadness and weeping due to Qi not rising to head.[2]

Forgetfulness is an important indication for this point: this is forgetfulness due to clear Qi not rising to the head.  According to the “Explanation of the Acupuncture Points”, this point treats forgetfulness by stimulating the ascending of Qi of both Lungs and Heart.[3]

Phlegm and Blood stasis in memory
Finally, it is important to remember that memory is affected by Full conditions, especially Phlegm and Blood stasis obstructing the Brain. This happens especially in the elderly.

In particular, Phlegm is a common cause of poor memory: when it is, poor memory is accompanied by dizziness and a feeling of heaviness and muzziness (fuzziness) of the head.  The tongue is swollen, illustrated below.

Points for Phlegm obstructing the Brain and affecting memory are: Du-20 Baihui, Du-24 Shenting, ST-40 Fenglong, LU-7 Lieque, Ren-9 Shuifen, Ren-5 Shimen, BL-22 Sanjiaoshu, P-5 Jianshi. 

These two tongues are both swollen, indicating Phlegm. 











[1]  Joseph Ledoux, The Emotional Brain, Simon and Shuster, NY, 1996, p. 278.

[2]  An Explanation of the Acupuncture Points (Jing Xue Jie), pp.  26-7.

[3]  Ibid., p.  27.

Thursday, January 28, 2016

GERIATRICS IN CHINESE MEDICINE

The thinking about geriatrics in Chinese medicine has been dominated by Kidney deficiency for centuries. As Kidney-Jing declines as we age, the clinical approach to the treatment of the elderly has been based largely on tonifying the Kidneys.

However, modern diseases of the elderly that account for 90% of mortality (cancer, heart disease and stroke) are characterized by Fullness. Quite simply, we do not die of Kidney deficiency but of Phlegm, Blood stasis and Internal Wind.

The most common pathogenic factors (and those leading to serious diseases) are:
Phlegm
Blood stasis
Internal Wind

Apart from the major diseases of the elderly such as cancer, stroke and heart disease, very many symptoms and signs that occur in old age are caused by Phlegm and/or Blood stasis. The following is a partial list.

GERIATRIC SYMPTOMS/SIGNS
•Otosclerosis: Phlegm/Blood stasis
•Cataract: Phlegm
•Macular degeneration (vascular, lack of blood nourishment): Blood stasis
•Dry eyes: may be due to Blood stasis
•Alzheimer: Phlegm (the neurofibrillary tangles and plaques in the brain are a form of
Phlegm)
•Parkinson: Wind
•Poor memory: is often due to Phlegm
•Brain muzziness: Phlegm
•Dizziness: Phlegm
•Epiretinal membrane: Phlegm
•Macules: Blood stasis
•Dry skin: in the elderly may be due to Blood stasis
•Itching: Phlegm/Wind
•Numbness: Phlegm/Wind
•Hair loss: may be due to Blood stasis

The following three Tables list the major diseases of the elderly with the pathology they are due to.

PHLEGM - BLOOD STASIS - WIND
Heart disease √ √
Angina √ √
Arteriosclerosis √ √
Thrombosis √
Atheroma √
Hypertension √ √ √

PHLEGM BLOOD STASIS WIND
Stroke √ √ √
Cholesterol √
Chronic bronchitis √
Cancer √ √
Diabetes √ √
Chronic nephritis √

PHLEGM BLOOD STASIS WIND
Prostatic hypertrophy/cancer √ √
Parkinson √
Alzheimer √ √
Trigeminal neuralgia √
Dizziness √ √

Many of the symptoms of the elderly are due to Phlegm:
Heart: mental confusion, feeling of oppression in the chest
Gall-Bladder: stones, nausea, inability to digest fats
Joints: bone deformities, pain, rigidity
Lungs: cough with mucus, feeling of oppression of the chest, asthma, breathlessness
Stomach: lack of appetite, digestive problems, hiatus hernia, acid reflux.
Skin: greasy skin, sweating, yellow moles.

TONGUE DIAGNOSIS IN THE ELDERLY
This has already been discussed in a previous blog (April 2010). The major pathogenic factors of the elderly manifest on the tongue with the following signs:

Phlegm: swollen tongue body, sticky coating
Blood stasis: purple, stiff body
Internal Wind: stiff, moving deviated.

For example, if we see a tongue that is swollen, purple and stiff, it indicates all three pathogenic factors of Phlegm, Blood stasis and internal Wind. When I see a tongue like that in an elderly patient, I actively invigorate Blood and resolve Phlegm for prevention.

TREATMENT PRINCIPLES IN DISEASES OF THE ELDERLY
Considering the above, I believe the most important treatment principles in the elderly are:
1) Invigorate Blood and eliminate stasis
2) Resolve Phlegm
3) Extinguish (internal) Wind

Some people think that eliminating pathogenic factors (with herbal medicine or acupuncture but especially with herbal medicine) may “weaken” the elderly. I have never found that to be true in practice: if an elderly person has Phlegm and Blood stasis, they will not be “weakened” by resolving Phlegm and invigorating Blood. Of course, one does need to adapt one’s doses to age so that dosages of herbs for the elderly should be lower than those for young people.

Monday, November 9, 2015

TREATMENT PRINCIPLES IN EXTERIOR INVASIONS

I recently received an email from a colleague asking for a help with a patient suffering from chronic fatigue syndrome.  The colleague was asking about the treatment principle to apply.  The patient obviously suffered from a deficiency of Zheng Qi, as all patients with chronic fatigue syndrome do.  But she also had frequent acute invasions of Wind.

The colleague was rightly following the principle that, in the presence of an acute invasion of Wind, one must expel pathogenic factors, in this case expelling Wind, and not tonify Zheng Qi.  In between invasions of Wind, the correct treatment principle is to tonify Zheng Qi, and this what the colleague was doing.

However, the problem was that the patient suffered from very frequent invasions of Wind, so that there was hardly any time to tonify Zheng Qi for a prolonged time.  She was using Yin Qiao San during the acute invasions of Wind and a Qi tonic to tonify Zheng Qi in between the acute attacks.

She wrote to me to ask whether taking a Qi tonic during an acute invasion of Wind could strengthen the pathogen.  She was also wondering whether one can go on taking Yin Qiao San for prolonged periods as the patient had times when she went from one acute illness to the next, so she could be taking Yin Qiao San for weeks, and my colleague was wondering whether this could deplete her Qi or Yin.

Her second question was whether taking a Qi tonic during an acute invasion of Wind could strengthen the pathogen.

I will try and answer here her questions.

1) Can one take a remedy that expels exterior Wind for prolonged periods?

The answer is basically: “no”.  Remedies that expel exterior Wind (such as Yin Qiao San) by definition should be taken only during an acute invasion of Wind for a few days.  After a few days or a week, either the exterior Wind has been expelled or the pathogenic factor has penetrated into the Interior at which time the patient needs a different treatment.

However, chronic fatigue syndrome presents a different situation and one that is not contemplated in Chinese books.  I have never seen a discussion of chronic fatigue syndrome in any Chinese book: indeed, a Chinese journal years ago published a translation of an article I wrote on chronic fatigue syndrome.

In my experience, chronic fatigue syndrome is characterized by a prolonged course of the disease with deficiency of Zheng Qi and frequent invasions of exterior Wind.  However, the exterior pathogen in such patients is “weak” and it is weak precisely because of the prolonged course of the disease and the prolonged deficiency of Zheng Qi.

So, in such cases, the patient may need to take a remedy that expels exterior Wind frequently, e.g. for a week every few weeks or so.  However, because the pathogen is weak, one can use a small dose such as for example only three tablets of Expel Wind-Heat a day.

2) Can tonifying the Zheng Qi also tonify an exterior pathogen?

Again, in theory “yes”.  However, again, chronic fatigue syndrome is an exception.  As the deficiency of Zheng Qi is very prolonged and the pathogen “weak”, during invasions of exterior Wind in chronic fatigue syndrome, I do occasionally combine expelling exterior Wind with Yin Qiao San with a Qi tonic, both in small doses.  For example, I might use 3 tablets of Qi tonic in the morning and 3 tablets of Yin Qiao San in the evening.


For a discussion of Chronic Fatigue Syndrome see chapter 41 of my book The Practice of Chinese Medicine, 2nd Edition.

Monday, October 5, 2015

THE SHEN, YI AND ZHI AND NEEDLING IN THE NEI JING

THE SHEN, YI AND ZHI AND NEEDLING IN THE NEI JING
The Nei Jing, and especially the Ling Shu, contains very many passages with instructions to acupuncturists as to how to needle. All these passages give instructions as to how to engage the Shen, Yi or Zhi (of the practitioner) when needling.

Just as a reminder, Yi is the mental faculty of the Spleen which refers to “focusing”, “attention”, “concentrating”, “idea”. Its character is based on the Heart radical which means that this mental faculty relies on the overlapping natures of Yi and Shen (and therefore Spleen and Heart).

意 Yi
心 Xin (heart)

Zhi of the Kidneys refers to “will power”, “intention”, “resolve”, “commitment” but also “memory”, “will”. Its character is based also on the heart radical together with the character for “Shi” which means scholar, soldier, gentleman, person trained in certain field, general, officer.

志 Zhi
士 Shi (scholar, soldier, gentleman, general, officer)

What is evident from all these passages is that the results one gets depend on the skill and sensitivity of the acupuncturist deriving from his or her Shen, Yi and Zhi. They are therefore very subjective: two acupuncturists may use the same points but the results may vary depending on the subjective application of the mental faculties of Shen, Yi and Zhi.

Ling Shu, chapter 1
“When holding the needle [literally “the Dao of holding the needle”], it should be held straight and not slanting to left or right. The [acupuncturist’s] Shen should be on the tip of the needle and his/her Yi on the disease.” Some translate the last few words as “the acupuncturist should concentrate his/her mind at the needle point and take good notice of the patient”. They therefore interpret the word bing, which means “disease”, as bing ren which means “patient”.1

Another source translates this as “When inserting the needle, the doctor should concentrate his mind on the patient.” Both these translations sound plausible but both miss the clear reference of the original to text to Shen and Yi as two separate mental faculties. Shen zai qiu hao, shu Yi bing zhe.2

Both these translations miss the beautiful idea that the “Shen should be on the needle and the Yi on the disease.” This makes complete sense if we consider that the Shen, besides cognition, is responsible for what we might call “muscle memory”. Shen, Yi and Shi, all three are responsible for memory but the Shen is responsible for “intrinsic” memory, i.e. for example remembering how to sew or ride a bike as opposed to remembering events, numbers, names, etc.

Thus, the Shen being on the tip of the needle refers to the skill, sensitivity and concentration of the acupuncturist. On the other hand, the Yi is responsible also for concentration, but also focusing, cognition, studying. That the Yi should be “on the disease” is a reference to the necessity of a laser-like diagnosis, pathology and treatment of the disease. Our acupuncturist’s skill would be for nothing if our diagnosis and treatment are wrong.

Ling Shu, chapter 9
“Concentrate the Shen on one point and the Zhi on the needle.” Notice the distinction between the Shen and the Zhi, similar to that between Shen and Yi of chapter 1. This distinction is completely lost in a modern Chinese translation: “Concentrate the attention and focus the whole mind on needling.”3

This statement is in the context of the description of the optimum conditions for needling a patient. “Acupuncturists should be in an isolated quite place, carefully observing the mental state [of the patient], close all doors and windows, tranquilize the mind, concentrate the attention.”

What they translate as “tranquilize the mind” is actually “so that Hun and Po are not scattered”; and what they translate as “concentrate the attention” is actually “focusing on Yi and concentrating the Shen”.

Ling Shu, chapter 8
The famous chapter 8 of the Ling Shu (entitled Ben Shen) is frequently quoted, especially its famous opening sentence. I would like to comment briefly on that sentence and propose a different translation of it.

The opening sentence of chapter 8 of the Ling Shu is: Fan ci zhi fa, xian bi ben yu shen 凡 刺 之 法 先 必 本 于 神 and the words mean literally “every needling’s method first must be rooted in Shen”. This sentence is usually translated as: “All treatment must be based on the Spirit”. The implication of this sentence is that all treatment must be based on the Spirit (of the patient), whatever interpretation we give to the word “Spirit”.

I propose an alternative translation with two important differences. Firstly, the text uses the word ci which means “to needle”, not “to treat”. If the text had meant to use the term “to treat”, it would have used the word zhi which does occur a lot in both the Su Wen and the Ling Shu. Thus, the first difference is that the first half of the sentence is “when needling” rather than “when treating”: this is an important difference.

The second difference is that the “Shen” referred to here may be interpreted as the Shen of the practitioner, not of the patient. Therefore, the whole sentence would mean: “When needling, one must first concentrate one’s mind [Shen]”. If that “Shen” is the Shen of the practitioner, then “Mind” would be a better translation here.

This interpretation is consistent with two factors. Firstly, the Ling Shu is very much an acupuncture text and therefore the reference to concentrating when needling makes sense. Secondly, the advice to concentrate and focus when needling is also found in many other places in the Nei Jing. Indeed, the word “shen” is even used occasionally to mean “needling sensation”. Chapter16 of the Su Wen says: “In Autumn needle the skin and the space between skin and muscles: stop when the needling sensation [shen] arrives.”

There are many passages in both the Ling Shu and Su Wen that stress the importance of concentrating one’s mind when needling. Indeed, chapter 25 of the Su Wen contains a sentence that is almost exactly the same as the opening sentence of the famous chapter 8 of the Ling Shu. Chapter 25 of the Su Wen contains this sentence: “fan ci zhi zhen, bi xian zhi shen”. 凡 刺 之 真必 先 治 神]. I would translate this so: “For reliable needling, one must first control one’s mind [shen].” Note the beautiful rhyming of “zhen” with “shen”.

The English translation of the Su Wen by Li Zhao Guo simply translates this sentence as “The key point for acupuncture is to pay full attention.”4 My interpretation is corroborated by the other paragraphs in that chapter which give advice as to how to practice needling. In fact, it says that the acupuncturist should not be distracted by people around or by any noise.

Unschuld, in his new translation of the Su Wen, translates this sentence as “For all piercing to be reliable, one must first regulate the spirit.”5 This translation would contradict mine but a footnote in the same book reports the interpretation of Wang Bing (the editor of the Nei Jing): “One must concentrate one’s mind and be calm without motion. This is the central point of piercing.”6 Notice that Unschuld says “piercing” and not “treating.”

Su Wen, chapter 54
This chapter has similar recommendations about concentrating while needling. It says: “Do not dare to be careless, as if one looked down into a deep abyss. The hand must be strong as if it held a tiger. The spirit [Shen] should not be confused by the multitude of things, that is have a tranquil mind [Zhi] and observe the patient, look neither to the left nor to the right.”7

After this passage, the text says that “one [the acupuncturist] must have a positive mind [Shen] by looking into the patient’s eyes and control his/her mind [Shen] so that Qi flows smoothly.”8

The modern Chinese translation of this passage is “To keep the mind [of the patient] concentrated means to prevent [the patient] from distracting his or her attention so as to make Qi flow smoothly.” The translator here takes the first reference to “shen” as the Shen of the patient while I interpret it as the Shen of the practitioner that must be concentrated.

Note how all meaning is lost when the Chinese medicine terms are translated. The distinction between Shen, Yi and Zhi when concentrating in needling is lost when these are translated as “attention”; or translating “so that Hun and Po are not scattered” as “tranquilizing the mind”; or translating “focusing on Yi and concentrating the Shen” as “concentrating the attention”; or translating the beautiful expression “the Shen on the tip of the needle and the Yi on the disease” as “when inserting the needle the doctor should concentrate his mind on the patient”; or translating “Jing-Shen not focused and Zhi and Yi not logical” as “cannot concentrate mind or make logical analysis”9; or “when the essence spirit is not concentrated and when the mind lack understanding”10.

As for the translation of “Shen” as “spirit” or “mind”, that would require a long dissertation. Suffice to say that in all these passages “Shen” refers to “concentration”, “analysis”, “focusing”. “attention” and therefore “mind” would be a better translation of it.

Acupuncture and shamanism
Shamanism was the form of healing prevalent in China before the Warring States Period (476-221 BC). Disease was caused by invasion of evil spirits (gui) and healing was performed by shamans reciting incantations. Shamans used to do this also fending the air with arrows and spears.

The character for “medicine” (Yi) in use before the Warring States Period is made up of the radicals for “ancient weapon made of bamboo” (shu), “quiver of arrows” (yi) and “shaman” (wu). During the Warring States Period the radical for “shaman” in the pictograph of “medicine” was replaced by the radical for herbal decoction: the shaman had been replaced by the herbalist.

医 quiver of arrows
殳 bamboo weapon
巫 shaman
穴 cave, acupuncture point (xue)

Evil spirits used to reside in “caves” called xue which is the same character as “acupuncture point”. I am of the opinion that shamanism was the origin of acupuncture: I think it is a short step between fending the air with an arrow to drive out evil spirits and actually piercing the body to drive out evil spirits from the “caves” in the body. I stress this is only my intuition and I have never read any corroboration of it.

The early connection between shamanism and acupuncture in my opinion is mirrored in the many Nei Jing passages describing the skill, intuition and sensitivity of the acupuncturist depending on his/her Shen. We are not shamans but there is a “shamanistic” quality to acupuncture, it is an art and it is very subjective.

I have noticed this also when I would get excellent results and the patient would feel very much better: whenever I repeated that same acupuncture treatment, it never yielded the same results because the conditions of the first treatment (influenced by subtle, subjective factors due to my Shen and its interaction with the patient’s Shen) could not be reproduced.

It is interesting that during the Northern Song dynasty (960–1127) there was a strong movement towards establishing medical schools and editing the classics of Chinese medicine (the Nei Jing was edited three times by imperial committees). As part of this “clean-up” of medicine, there was a drive towards eliminating shamans and the shamanism that was prevalent in the South.

During the Northern Song dynasty, southerners’ medical customs and reliance on shamans were considered almost “barbaric” usually in a degree increasing with their distance from the northern centre. Their deities were labelled “demons” (gui), their religious officiants were labelled shamans (wu) and their healing practices were described as noxious.11

Song officials’ concern focused on the southerners’ preference for local shamans over physicians which was seen as the root of their ignorance of medicine. In some prefectures, prefects even forced shamans to change occupation and apply themselves to acupuncture! Their shrines were destroyed.12

If acupuncture has indeed shamanistic qualities (much more than herbal medicine), it may explain the difficulties of conducting acupuncture clinical trials. An acupuncture treatment is subject to very many variables, to the subjective state of the practitioner’s Shen, to the interaction with the patient’s Shen, to the intent, skill and sensitivity of the acupuncturist, all of which may make it difficult to conduct clinical trials, especially if they are based on a standard acupuncture “prescription”. Even in modern China, acupuncture doctors teach about directing the needling sensation simply with the power of Shen. For example, in Nanjing they taught us that, in order to direct the needling sensation downwards along a channel, we should press with the thumb behind the point and visualize with our Shen the downward movement of Qi along the channel.

END NOTES
1. Wu N L, Wu A Q Yellow Emperor’s Canon of Internal Medicine, China Science and Technology Press, Beijing, 1999, p. 495.
2. Li Z G, Liu X R, Yellow Emperor’s Canon of Medicine - Spiritual Pivot, World Publishing Corporation, Xi’an, 2008, p. 9.
3. Ibid., p. 179.
4. Li Zhao Guo (translator) Yellow Emperor’s Canon of Medicine, Library of Chinese Classics, World Publishing Corporation, Xi’an, 2005, p. 335.
5. Unschuld P U and Tessenow H, Huang Di Nei Jing Su Wen – An Annotated Translation of the Huang Di’s Inner Classic – Basic Questions, Vol. I, University of California Press, Berkeley, 2011, p. 428.
6. Ibid., p. 428.
7. Unschuld, p. 19.
8. Li Zhao Guo (translator) Yellow Emperor’s Canon of Medicine, Library of Chinese Classics, World Publishing Corporation, Xi’an, 2005, p. 601.
9. Ibid., p. 1261.
10. Unschuld, p. 681.
11. Hinrichs T J, Barnes L L, Chinese Medicine and Healing, Harvard University Press, Cambridge, Massachusetts, 2013, p. 109.
12. Ibid., p. 109.